High Value_SOC_072020 053295005.32.950.1 (5/20)
High Value Plan – July 1, 2020 updates There will be changes to the
High Value Plan drug list that applies to your plan starting July
1, 2020. It’s important that you review and understand the changes
in the chart below. Talk to your health care provider about how
these changes might impact you.
What if I need a prescription drug that requires a medical
exception?
You or your prescriber can request a medical exception to the
changes in this letter. If you would like to ask for a medical
exception, speak directly with your prescriber or you can call us
at the toll-free number on your member ID card. We’ll contact you
and your prescriber with our decision. If your exception is
approved, you only need to pay your plan copay or cost-share. This
amount is based on your pharmacy plan design.
How to find a preferred medicine that’s right for you
You can visit the website that’s on your member ID card and sign
into your account.
Key
Condition Drug name Alternative(s)
adapalene, benzoyl peroxide, clindamycin gel, solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin
Cancer TOTECT Consult doctor
FORFIVO XL: bupropion, bupropion ER (except 450 mg ER tablet)
Eye Disorders bimatoprost ophth sol 0.03% latanoprost
Gastrointestinal sucralfate susp (NDC 65162006205) sucralfate
Infection ACTICLATE, ANCOBON, COREMINO, DORYX, doxycycline hyclate
50mg (NDC 72143021160), doxycycline monohydrate 75mg and 150mg),
NOXAFIL, SOLODYN
ANCOBON: fluconazole
NOXAFIL: fluconazole, itraconazole, voriconazole
Migraine CAFERGOT, sumatriptan-naproxen sodium
Pain AMRIX, LORZONE, ketoprofen, naproxen (NDC 69420137501),
NORGESIC FORTE, tramadol (NDC 52817019610), VIMOVO
AMRIX, LORZONE, NORGESIC FORTE: carisoprodol, chlorzoxazone 500mg,
cyclobenzaprine (except cyclobenzaprine tablet 7.5mg), metaxalone,
methocarbamol
ketoprofen, naproxen: diclofenac sodium, ibuprofen, meloxicam
tramadol: tramadol (except NDC 52817019610), tramadol XR
VIMOVO: diclofenac sodium, ibuprofen, meloxicam, naproxen (except
naproxen CR or naproxen suspension) PLUS esomeprazole,
lansoprazole, omeprazole, pantoprazole
Skin Disorders flurandrenolide lotion 0.05%, hydrocortisone
butyrate hydrophilic lipo base cream 0.1%, KENALOG SPRAY
flurandrenolide: desonide, hydrocortisone, Hydrocortisone butyrate
hydrophilic lipo base cream 0.1%,
KENALOG SPRAY: hydrocortisone butyrate cream, hydrocortisone
butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone
butyrate solution, mometasone, triamcinolone cream, triamcinolone
lotion, triamcinolone ointment
Vitamins QUFLORA Consult doctor
Condition Drug name
Hereditary Angioedema TAKHZYRO
HIV SYMTUZA
Aetna is the brand name used for products and services provided by
one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company, and their affiliates (Aetna).
Health benefits and health insurance plans are offered,
administered and/or underwritten by Aetna Health Inc., Aetna Health
Insurance Company of New York, Aetna HealthAssurance Pennsylvania
Inc., Aetna Health Insurance Company and/or Aetna Life Insurance
Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life
Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc.
and Aetna Life Insurance Company. In Maryland, by Aetna Health
Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has
sole financial responsibility for its own products.
Not all health services are covered. See plan documents for a
complete description of benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by
location and are subject to change. The drugs on the Pharmacy Drug
Guide (formulary), Formulary Exclusions, Precertification, Quantity
Limit and Step Therapy Lists are subject to change.
This material is for information only. It contains only a partial,
general description of plan benefits or programs and does not
constitute a contract.
Aetna is part of the CVS Health family of companies.
©2020 Aetna Inc. 05.32.950.1 (5/20)
Aetna complies with applicable Federal civil rights laws and does
not discriminate, exclude or treat people differently based on
their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and
to people who need language assistance.
If you need a qualified interpreter, written information in other
formats, translation or other services, call the number on your ID
card. If you believe we have failed to provide these services or
otherwise discriminated based on a protected class noted above, you
can also file a grievance with the Civil Rights Coordinator by
contacting: Civil Rights Coordinator, P.O. Box 14462, L exington, K
Y 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers:
860-262-7705),
[email protected].
You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S.
Department of Health and Human Services, 200 Independence Avenue
SW., Room 509F, HHH Building, Washington, DC 20201, or at
1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by
one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company, Coventry Health Care plans and their
affiliates (Aetna).
TTY: 711
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